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Keskin Perk FFN, Tanriverdi C, Karaca ZY, Tran KD, Kilic A. Long-Term Results of Sterile Corneal Allograft Ring Segments Implantation in Keratoconus Treatment. Cornea 2024:00003226-990000000-00581. [PMID: 38900741 DOI: 10.1097/ico.0000000000003592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/05/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE To evaluate the efficacy and safety of sterile corneal allograft ring segments implantation for the treatment of keratoconus by analyzing long-term visual, refractive, and tomographic clinical outcomes. METHODS This prospective study included 62 eyes of 49 patients with keratoconus who underwent corneal allograft ring segments implantation at Istanbul Medipol University Faculty of Medicine between February 2020 and August 2022. Surgical outcomes using the Istanbul nomogram were evaluated in patients preoperatively and postoperatively at 1 month, 6 months, 1 year, and 3 years. Outcomes measured were uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE), spherical refraction (SR), cylindrical refraction (CR), topographic keratometric values, and corneal thickness at the thinnest point. RESULTS Preoperative mean UDVA and CDVA (LogMAR) were 0.96 ± 0.50 and 0.72 ± 0.47, respectively, and increased to 0.41 ± 0.34 and 0.22 ± 0.19 at the last visit (P < 0.001). There was a significant decrease in SE, SR, and keratometric values postoperatively (P < 0.001). There was no difference in CR and thinnest corneal thickness values (P = 0.333 and 0.154, respectively). The stromal and epithelial thicknesses measured by anterior segment optical coherence tomography were stabilized at 6 months and 1 year, respectively. No major complications or side effects were observed intraoperatively or postoperatively. CONCLUSIONS This study demonstrated that sterile corneal allograft ring segments implantation is a safe and feasible treatment for keratoconus, yielding notable long-term visual outcomes with minimal implant-related complications.
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Affiliation(s)
| | - Cafer Tanriverdi
- Department of Ophthalmology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey
| | - Zeki Yigit Karaca
- Department of Ophthalmology, Istanbul Medipol University, Faculty of Medicine, Istanbul, Turkey
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Jacob S, Agarwal A, Awwad ST, Mazzotta C, Parashar P, Jambulingam S. Customized corneal allogenic intrastromal ring segments (CAIRS) for keratoconus with decentered asymmetric cone. Indian J Ophthalmol 2023; 71:3723-3729. [PMID: 37991313 PMCID: PMC10788746 DOI: 10.4103/ijo.ijo_1988_23] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 11/01/2023] [Accepted: 11/06/2023] [Indexed: 11/23/2023] Open
Abstract
Corneal allogenic intrastromal ring segments (CAIRS) refer to the intracorneal placement of fresh, unprocessed, processed, preserved, or packaged allogenic rings/segments of any type/length. We described uniform-thickness CAIRS previously. We now describe a new technique of customized CAIRS to personalize the flattening effect as per individual topography. A prospective interventional case series of patients with pericentral/ paracentral decentered cones and gradation of keratometry with one side steeper than the other was conducted. Individually customized tapered CAIRS with variable volume, arc length, taper length, and gradient of taper were implanted. In total, 32 eyes of 29 patients with at least 1-year follow-up were included. Special double-bladed trephines and a CAIRS customizer template allowed the creation of individually customized CAIRS. Mean uncorrected distance visual acuity (UDVA) and spectacle-corrected distance visual acuity improved from 0.22 to 0.47 (P = 0.000) and from 0.76 to 0.89 (P = 0.001), respectively. Significant improvement was seen in K1, K2, Km, Kmax, topographic astigmatism, Q-value, sphere, cylinder, spherical equivalent, Root Mean Square (RMS), Higher Order Aberrations (HOA), and vertical coma (P < 0.01, 0.05). There was no significant change in the width or height of CAIRS between 1 month and last visit on anterior-segment optical coherence tomography. Five eyes continued to remain at the same UDVA, 27 eyes had at least 2 lines, and 13 eyes had at least 3 or more lines improvement in UDVA. The maximum improvement in UDVA was 7 lines. A significant difference in flattening was obtained at different zones across the tapered CAIRS. Thus, differential flattening was achieved across the cone based on the customization plan. Personalized customization was possible for each cornea, unlike limited models of progressive-thickness synthetic segments. Allogenic nature, greater customizability, efficacy, and absent need for large inventories are advantages compared to synthetic segments.
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Affiliation(s)
- Soosan Jacob
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
| | - Amar Agarwal
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
| | - Shady T Awwad
- Department of Ophthalmology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Cosimo Mazzotta
- Departmental Ophthalmology Unit, Alta Val D'elsa Hospital, USL Toscana Sudest, Italy
- Siena Crosslinking Center, Italy
| | - Parnika Parashar
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
| | - Sambath Jambulingam
- Department of Cornea, Dr. Agarwal's Eye Hospital and Eye Research Centre, Chennai, Tamil Nadu, India
- Department of Cornea, Dr. Agarwal's Refractive and Cornea Foundation, Chennai, Tamil Nadu, India
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Bteich Y, Assaf JF, Mrad AA, Jacob S, Hafezi F, Awwad ST. Corneal Allogenic Intrastromal Ring Segments (CAIRS) for Corneal Ectasia: A Comprehensive Segmental Tomography Evaluation. J Refract Surg 2023; 39:767-776. [PMID: 37937759 DOI: 10.3928/1081597x-20231011-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023]
Abstract
PURPOSE To evaluate the visual, refractive, and tomographic results of patients with corneal ectasia treated with corneal allogenic intrastromal ring segments (CAIRS) insertion without concomitant corneal cross-linking. METHODS Fifty-two eyes from 39 patients with stable corneal ectasia and unsatisfactory visual acuity with contact lenses were included. All patients underwent CAIRS insertion with no concomitant corneal procedure at the American University of Beirut Medical Center between September 2019 and July 2022. Visual, refractive, topographic, aberrometric, epithelial, stromal, and segment thickness data were measured relative to baseline at 1 week, 1 month, and at least 3 months postoperatively. Evaluations included slit-lamp examination, manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and tomography using anterior segment optical coherence tomography. RESULTS Mean follow-up time was 6.9 ± 5.2 months. UDVA and CDVA improved from 0.97 ± 0.47 and 0.56 ± 0.19 preoperatively to 0.52 ± 0.21 (P < .001) and 0.23 ± 0.19 (P < .001) 3 months postoperatively. Manifest refraction spherical equivalent and cylinder improved from -6.71 ± 6.51 and -4.02 ± 2.24 diopters (D) preoperatively to -3.78 ± 4.07 D (P < .001) and -2.35 ± 1.98 D (P < .001) 3 months postoperatively, respectively. Maximum anterior keratometry and vertical coma decreased from 58.09 ± 7.92 D and 1.56 ± 1.09 µm to 52.48 ± 6.69 D (P < .001) and 0.43 ± 0.77 µm, respectively (P < .001). Corneal epithelium thickened proximal to the allogenic segment by 7.25 µm (P < .001), whereas stromal elevation at the cone decreased from 38.61 ± 18.5 to 23.82 ± 13.4 µm, respectively (P < .001). No major complications were observed and only 1 eye lost one line of CDVA. CONCLUSIONS Treatment of corneal ectasia with CAIRS improved visual, refractive, topographic, and tomographic parameters. Epithelial thickening central to CAIRS, along with anterior stromal flattening is postulated to contribute to tomographic flattening and regularization. [J Refract Surg. 2023;39(11):767-776.].
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Haciagaoglu S, Tanriverdi C, Keskin FFN, Tran KD, Kilic A. Allograft corneal ring segment for keratoconus management: Istanbul nomogram clinical results. Eur J Ophthalmol 2022; 33:11206721221142995. [PMID: 36464653 DOI: 10.1177/11206721221142995] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE To evaluate the clinical feasibility and visual outcomes of allograft corneal ring segment implantation for the treatment of keratoconus. METHODS This case series, included forty-four eyes of 32 patients with a 6-month follow-up. All cases were treated according to the Istanbul nomogram. In the Istanbul Nomogram, corneal tunnels of 4 × 7.5 mm diameters are created at depth of 200 μm and implanted with sterile allograft corneal rings (KeraNaturalTM, Lions VisionGift, Portland, OR, USA) at the cone location. Uncorrected distance visual acuity (UDVA), corrected distance visual acuity (CDVA), spherical equivalent (SE) and keratometric values were compared preoperatively versus postoperatively. RESULTS There was significant improvement in UDVA, CDVA, SE and topographic keratometric values. The mean preoperative CDVA (Snellen, decimal) increased from 0.29 ± 0.20, to 0.56 ± 0.26 (P < 0.001), at the last visit. There was no statistically significant difference between preoperative and postoperative thinnest pachymetry values (P = 0.509). No major complications or adverse event were observed during and after the operation. CONCLUSIONS The results of this pilot study show that sterile allograft corneal ring segments may be safe, effective and enhance the visual performance of keratoconus patients. Larger clinical studies are needed to demonstrate the effectiveness and safety with long term follow-up.
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Affiliation(s)
- Sezer Haciagaoglu
- Faculty of Medicine, Department of Ophthalmology, Medipol University, Istanbul, Turkey
| | - Cafer Tanriverdi
- Faculty of Medicine, Department of Ophthalmology, Medipol University, Istanbul, Turkey
| | | | | | - Aylin Kilic
- Faculty of Medicine, Department of Ophthalmology, Medipol University, Istanbul, Turkey
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Moshirfar M, Milner DC, Martheswaran T, McCabe SE, Ronquillo YC, Hoopes PC. Delayed Perforation of an Intrastromal Corneal Ring Segment into the Anterior Chamber: A Case Report and Review of the Literature. Case Rep Ophthalmol 2021; 12:740-748. [PMID: 34720972 PMCID: PMC8460883 DOI: 10.1159/000518012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 06/20/2021] [Indexed: 11/19/2022] Open
Abstract
Intrastromal corneal ring segments (ICRSs) are an effective treatment for stabilizing and normalizing corneal shape in patients with keratoconus and other corneal ectasias. Intraoperative segment perforation through the corneal endothelium into the anterior chamber (AC) is an uncommon but known complication. However, perforation into the AC postoperatively is an exceedingly rare complication with only 3 reported cases in the literature. One case was due to Descemet membrane detachment and another due to ocular trauma. In the third case, the mechanism for perforation was unclear. We present the fourth case of delayed ICRS perforation due to silent migration through the endothelium into the AC. We also present all reported cases in the literature of intraoperative and postoperative perforation into the AC.
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Affiliation(s)
- Majid Moshirfar
- Hoopes Vision Research Center, Hoopes Vision, Draper, Utah, USA.,John A. Moran Eye Center, University of Utah School of Medicine, Salt Lake City, Utah, USA.,Utah Lions Eye Bank, Murray, Utah, USA
| | - Dallin C Milner
- University of Colorado School of Medicine, Aurora, Colorado, USA
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Jafarinasab M, Hadi Y. Femtosecond laser-assisted peripheral additive stromal keratoplasty for treatment of primary corneal ectasia: Preliminary outcomes. Indian J Ophthalmol 2021; 69:2663-2668. [PMID: 34571610 PMCID: PMC8597526 DOI: 10.4103/ijo.ijo_3206_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Purpose: To report the preliminary results of a new surgical modality for the treatment of primary corneal ectasia, which consists of implanting allogeneic corneal tissue into the peripheral corneal stroma using a femtosecond laser system or femtosecond laser-assisted peripheral allogeneic stromal additive keratoplasty or FA-PASAK. Methods: This prospective, noncomparative case series includes patients with primary corneal ectasia including keratoconus and pellucid marginal degeneration. In the operating room, one or two ring or crescent-shaped allogeneic corneal segments were prepared using a handmade double-bladed punch, which were then implanted by a specially designed device, into stromal channels in the peripheral recipient cornea fashioned with a femtosecond-laser system. Results: A total of 15 eyes of 13 patients with mean age of 31.73 years were operated. There were significant improvements in uncorrected (0.68 to 0.3 logMAR) and corrected (0.44 to 0.16 logMAR) visual acuity, mean sphere, mean spherical equivalent refractive error, and mean keratometry (steep, flat, and average). Topographic and refractive astigmatism did not change significantly. Complications included a single case of bacterial keratitis secondary to epithelial defect, which was controlled with topical antibiotics eventually leading to an uncorrected vision of 20/25 one year after surgery. Conclusion: The use of allogeneic corneal ring or crescent shape segments may be a safe and cost-effective treatment for primary corneal ectasia, whereas a nomogram is necessary to be devised for general use of the technique.
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Affiliation(s)
- Mohammadreza Jafarinasab
- Eye Research Center, Shahid Labbafi Nejad Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Yasaman Hadi
- Eye Research Center, Five Senses Institute, Rassoul Akram Hospital, Iran University of Medical Sciences, Tehran, Iran
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Ormonde S. Refractive surgery for keratoconus. Clin Exp Optom 2021; 96:173-82. [DOI: 10.1111/cxo.12051] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 01/31/2013] [Accepted: 02/03/2013] [Indexed: 11/28/2022] Open
Affiliation(s)
- Sue Ormonde
- Department of Ophthalmology, University of Auckland, Auckland, New Zealand,
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Eliaçık M, Kırgız A, Tülü Aygün B. Evaluation of corneal thickness with spectral-domain optical coherence tomography following keraring implantation for keratoconus: five year follow-up. Curr Eye Res 2020; 45:1359-1363. [PMID: 32228114 DOI: 10.1080/02713683.2020.1749667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
To evaluate the change in the position of intrastromal corneal ring segments (ICRS) implanted in keratoconus patients within five years of implantation. Participants in this study included keratoconus patients who received Keraring 10 ICRS implantation and had a follow-up time of at least 5 years. The distances from apex to anterior corneal surface (AA), from outer basal corner to posterior corneal surface (BP), and from inner basal corner to posterior corneal surface (CP) were measured at every postoperative visit (6 months, 1 year, 3 years, and 5 years) and compared to each other. Thirty eyes of 22 patients were included. The CP showed a statistically significant decrease at all 15 time points (p < .001); however, no statistically significant difference was found at 5 years regarding AA or BP (p > .05 for all). Triangular ICRS implanted in keratoconus patients remained stable for five years without any complications, which is an extremely important aspect of ICRS surgery. The only difference was a slight posterior movement of the inner basal corner, although without anterior chamber perforation.
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Affiliation(s)
- Mustafa Eliaçık
- School of Medicine, Department of Ophthalmology, Medipol University , Istanbul, Turkey
| | - Ahmet Kırgız
- Ophthalmology Department, Beyoglu Eye Training and Research Hospital, University of Health Sciences , Istanbul, Turkey
| | - Beril Tülü Aygün
- Ophthalmology Department, Beyoglu Eye Training and Research Hospital, University of Health Sciences , Istanbul, Turkey
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Jacob S, Patel SR, Agarwal A, Ramalingam A, Saijimol AI, Raj JM. Corneal Allogenic Intrastromal Ring Segments (CAIRS) Combined With Corneal Cross-linking for Keratoconus. J Refract Surg 2018; 34:296-303. [PMID: 29738584 DOI: 10.3928/1081597x-20180223-01] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 01/22/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE To describe a new technique for the treatment of keratoconus using corneal allogenic intrastromal ring segments (CAIRS). METHODS CAIRS trephined from donor cornea using a double-bladed trephine were implanted into mid-depth femtosecond laser-dissected channels in the cornea of patients with keratoconus in the 6.5-mm optic zone, followed by accelerated corneal cross-linking (A-CXL)-either conventional or contact lens-assisted CXL (A-CACXL), depending on minimum corneal thickness. RESULTS Twenty patients (24 eyes) with stage 1 to 4 keratoconus (Amsler-Krumeich grading) were included. Mean follow-up was 11.58 ± 3.6 months (range: 6 to 18 months). There was significant improvement in uncorrected (2.79 ± 2.65 lines; range: 0 to 8 lines) and corrected (1.29 ± 1.33 lines; range: 0 to 5 lines) distance visual acuity, spherical equivalent, simulated maximum keratometry, steepest keratometry, topographic astigmatism, anterior and posterior best fit spheres, and mean power in the 3- and 5-mm zones. No eye showed progression during the entire follow-up. All segments remained well positioned and no segment-induced complications were seen. No other major intraoperative or postoperative complications were observed. CONCLUSIONS This pilot study indicates that CAIRS with CXL may be a simple, safe, and effective option for treating keratoconus. Further studies are recommended to determine long-term outcomes. [J Refract Surg. 2018;34(5):296-303.].
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Corneal Hydrops Secondary to Intrastromal Corneal Ring Intrusion into the Anterior Chamber 7 Years after Implantation: A Case Report. Ophthalmol Ther 2017; 6:373-379. [PMID: 28849554 PMCID: PMC5693822 DOI: 10.1007/s40123-017-0105-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION This report describes the first known case of late-onset intrusion of an intrastromal ring segment into the anterior chamber due to posterior migration of a ring segment. To our knowledge, intrastromal ring segment penetration has only been shown to occur in the intraoperative or immediate postoperative period. We postulate that the perforation in this case is due to progressive thinning of the cornea, possibly in combination with habitual eye rubbing. CASE REPORT A 44-year-old man presented with acute corneal hydrops related to penetration of Descemet's membrane and endothelium by an intrastromal ring segment implanted 7 years prior. Removal of the ring segment resulted in an anterior chamber fistula that directed fluid through the ring segment tunnel to the ocular surface. Leakage of aqueous humor was successfully controlled, and corneal edema gradually resolved. CONCLUSION This case indicates the need for long term monitoring of ring segment proximity to the posterior corneal surface, especially in patients with ectatic ocular conditions and/or habitual eye rubbing behavior.
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Reshaping procedures for the surgical management of corneal ectasia. J Cataract Refract Surg 2015; 41:842-72. [PMID: 25840308 DOI: 10.1016/j.jcrs.2015.03.010] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/15/2014] [Accepted: 07/23/2014] [Indexed: 12/31/2022]
Abstract
UNLABELLED Corneal ectasia is a progressive, degenerative, and noninflammatory thinning disorder of the cornea. Recently developed corneal reshaping techniques have expanded the treatment armamentarium available to the corneal specialist by offering effective nontransplant options. This review summarizes the current evidence base for corneal collagen crosslinking, topography-guided photorefractive keratectomy, and intrastromal corneal ring segment implantation for the treatment of corneal ectasia by analyzing the data published between the years 2000 and 2014. FINANCIAL DISCLOSURE No author has a financial or proprietary interest in any material or method mentioned.
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Parker JS, van Dijk K, Melles GRJ. Treatment options for advanced keratoconus: A review. Surv Ophthalmol 2015; 60:459-80. [PMID: 26077628 DOI: 10.1016/j.survophthal.2015.02.004] [Citation(s) in RCA: 108] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/17/2015] [Accepted: 02/20/2015] [Indexed: 10/23/2022]
Abstract
Traditionally, the mainstay of treatment for advanced keratoconus (KC) has been either penetrating or deep anterior lamellar keratoplasty (PK or DALK, respectively). The success of both operations, however, has been somewhat tempered by potential difficulties and complications, both intraoperatively and postoperatively. These include suture and wound-healing problems, progression of disease in the recipient rim, allograft reaction, and persistent irregular astigmatism. Taken together, these have been the inspiration for an ongoing search for less troublesome therapeutic alternatives. These include ultraviolet crosslinking and intracorneal ring segments, both of which were originally constrained in their indication exclusively to eyes with mild to moderate disease. More recently, Bowman layer transplantation has been introduced for reversing corneal ectasia in eyes with advanced KC, re-enabling comfortable contact lens wear and permitting PK and DALK to be postponed or avoided entirely. We offer a summary of the current and emerging treatment options for advanced KC, aiming to provide the corneal specialist useful information in selecting the optimal therapy for individual patients.
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Affiliation(s)
- Jack S Parker
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; UAB Callahan Eye Hospital, Birmingham, Alabama, USA
| | - Korine van Dijk
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands
| | - Gerrit R J Melles
- Netherlands Institute for Innovative Ocular Surgery, Rotterdam, The Netherlands; Melles Cornea Clinic, Rotterdam, The Netherlands; Amnitrans EyeBank, Rotterdam, The Netherlands.
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